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Abstract:

Apparatus comprises: (A) a housing (248), percutaneously deliverable to a
heart of a subject, slidable along a guidewire (242), and shaped to
define at least one opening (249); (B) a guide member (250),
percutaneously deliverable to the heart, percutaneously removable from
the subject, couplable to the housing, and having: (i) a distal portion,
comprising a chord-engaging element (252), configured to be
percutaneously slidably coupled to and decouplable from at least one
chordae tendineae (244), and (ii) a proximal portion, comprising a
longitudinal element (251); and (C) a deployment tool, configured (i) to
be reversibly coupled to a tissue anchor (50,280), (ii) to be slidably
coupled to the longitudinal element of the guide member, and (iii) to
anchor the tissue anchor to a papillary muscle (254) of the subject.
Other embodiments are also described.

Claims:

1. Apparatus for facilitating anchoring of a tissue anchor to a papillary
muscle of a heart of a subject, the papillary muscle being coupled to one
or more chordae tendineae of the heart of the subject, the apparatus
being configured to be used with a guidewire, and comprising: a housing,
percutaneously deliverable to the heart of the subject, slidable along
the guidewire, and shaped to define at least one opening; a guide member,
percutaneously deliverable to the heart of the subject, percutaneously
removable from the subject, couplable to the housing, and having: a
distal portion, comprising a chord-engaging element, configured to be
percutaneously slidably coupled to at least one of the one or more
chordae tendineae, and decouplable from the at least one of the one or
more chordae, and a proximal portion, comprising a longitudinal element;
and a deployment tool, configured (1) to be reversibly coupled to the
anchor, (2) to be slidably coupled to the longitudinal element of the
guide member, and (3) to anchor the tissue anchor to the papillary muscle
of the subject.

2. The apparatus according to claim 1, wherein the housing is configured
to be decoupled from the guide member before the deployment tool is
coupled to the guide member.

3. The apparatus according to claim 1, wherein the tissue anchor
comprises a helical tissue anchor, and wherein the deployment tool is
configured to anchor the tissue anchor to the papillary muscle of the
subject by rotating the tissue anchor.

4. The apparatus according to claim 1, wherein the deployment tool
comprises a lance, configured to stabilize the deployment tool at the
papillary muscle of the subject by penetrating tissue of the papillary
muscle.

5. The apparatus according to claim 4, wherein the lance is retractable
into the deployment tool.

6. The apparatus according to claim 1, further comprising the anchor.

7. The apparatus according to claim 6, wherein the guidewire comprises a
first guidewire, and wherein the apparatus further comprises a second
guidewire, reversibly coupled to the anchor.

8. The apparatus according to claim 1, further comprising the guidewire,
the guidewire being configured to be transluminally advanced to a
vicinity of the one or more chordae tendineae of the subject.

9. The apparatus according to claim 8, wherein the guidewire is
configured to be transluminally advanced such that a distal portion of
the guidewire is disposed between at least two chordae tendineae of the
subject, the one or more chordae tendineae including at least one of the
at least two chordae tendineae of the subject.

10. The apparatus according to claim 8, wherein the housing is shaped to
define a channel therethrough, the housing being slidable along the
guidewire by the guidewire being slidable through the channel.

11. The apparatus according to claim 1, wherein the chord-engaging
element comprises a helical element, configured to be housed by the
housing, to be advanced out of the housing, and to form a helix outside
of the housing.

12. The apparatus according to claim 11, wherein the chord-engaging
element is configured to be generally straight when housed by the
housing, and to curl into the helix outside of the housing.

13. The apparatus according to claim 11, wherein the chord-engaging
element is configured to be helical when housed by the housing.

14. A method for use with a papillary muscle of a heart of a subject, the
papillary muscle being coupled to one or more chordae tendineae of the
heart of the subject, the method comprising: advancing a guide member to
the chordae tendineae, the guide member having a proximal portion that
includes a longitudinal element, and a distal portion that includes a
chord-engaging element, configured to be slidably coupled to the chordae
tendineae; coupling the chord-engaging element to at least one of the one
or more chordae tendineae; sliding the chord-engaging element over the at
least one of the chordae tendineae toward the papillary muscle; and
advancing a tool toward the papillary muscle of the subject by sliding
the tool along the longitudinal element.

15. The method according to claim 14, wherein the chord-engaging element
includes a helical chord-engaging element, and wherein coupling the
chord-engaging element to the at least one of the chordae tendineae
comprises wrapping the helical chord-engaging element around the at least
one of the chordae tendineae.

16. The method according to claim 14, further comprising, following the
step of advancing, anchoring a tissue anchor to ventricular muscle tissue
using the tool.

17. The method according to claim 16, wherein anchoring the tissue anchor
comprises anchoring the tissue anchor to ventricular muscle tissue in a
vicinity of the papillary muscle.

18. The method according to claim 17, wherein anchoring the tissue anchor
comprises anchoring the tissue anchor to ventricular muscle tissue within
1 cm of the papillary muscle.

19. The method according to claim 17, wherein anchoring the tissue anchor
comprises anchoring the tissue anchor to the papillary muscle.

20. The method according to claim 16, wherein anchoring the tissue anchor
comprises anchoring a tissue anchor that is reversibly couplable to a
guidewire.

21. The method according to claim 16, wherein the deployment tool
includes a lance, and the method further comprises, prior to anchoring
the tissue anchor, stabilizing the tool with respect to the ventricular
muscle tissue by penetrating the ventricular muscle tissue with the
lance.

22. The method according to claim 21, further comprising retracting the
lance into the deployment tool.

23. The method according to claim 14, wherein the step of advancing
comprises advancing, to the heart of the subject, a housing that is
slidable along the guide member.

24. The method according to claim 23, further comprising, prior to the
step of advancing, advancing a guidewire to a ventricle of the heart,
wherein advancing the housing comprises sliding the housing over the
guidewire.

25. The method according to claim 24, wherein advancing the guidewire
comprises advancing a distal portion of the guidewire between at least
two of the chordae tendineae of the subject.

26. The method according to claim 23, further comprising, subsequent to
the step of advancing, sliding the chord-engaging element distally out of
the housing.

27. The method according to claim 26, further comprising, subsequent to
the step of coupling and prior to the step of advancing, proximally
withdrawing the housing and decoupling the housing from the guide member
while maintaining the coupling of the chord-engaging element to the at
least one of the one or more chordae tendineae.

28. The method according to claim 26, wherein sliding the chord-engaging
element distally out of the housing comprises facilitating transitioning
of the chord-engaging element from a generally straight state into a
helical state.

29-43. (canceled)

Description:

CROSS-REFERENCES TO RELATED APPLICATIONS

[0001] The present application claims priority from U.S. Provisional
Patent application 61/733,979 to Reich et al., filed Dec. 6, 2012, and
entitled "Techniques for guide-wire based advancement of a tool"; and is
related to:

[0002] (a) International Application PCT/IL2011/000446 to Miller et al.,
entitled "Apparatus and method for guide-wire based advancement of a
rotation assembly," filed on Jun. 6, 2011 (which published as
WO/2011/154942);

[0003] (b) U.S. patent application Ser. No. 12/795,192 to Miller et al.,
entitled "A method for guide-wire based advancement of a rotation
assembly," filed on Jun. 7, 2010 (which published as US 2011/0301698);

[0004] (c) U.S. patent application Ser. No. 12/795,026 to Miller et al.,
entitled "Apparatus for guide-wire based advancement of a rotation
assembly," filed on Jun. 7, 2010 (which published as US 2011/0106245),
which is a continuation-in-part of U.S. patent application Ser. No.
12/608,316 to Miller et al., entitled, "Tissue anchor for annuloplasty
device," filed on Oct. 29, 2009 (now U.S. Pat. No. 8,277,502); and

[0005] (d) U.S. patent application Ser. No. 13/707,013 to Reich et al.,
entitled "Apparatus and method for guide-wire based advancement of a
rotation assembly", filed on Dec. 6, 2012 (which published as US
2013/0096672).

[0006] All of these applications are incorporated herein by reference.

FIELD OF THE INVENTION

[0007] The present invention relates in general to valve and chordae
tendineae repair. More specifically, the present invention relates to
repair of an atrioventricular valve and associated chordae tendineae of a
patient.

BACKGROUND

[0008] Ischemic heart disease causes mitral regurgitation by the
combination of ischemic dysfunction of the papillary muscles, and the
dilatation of the left ventricle that is present in ischemic heart
disease, with the subsequent displacement of the papillary muscles and
the dilatation of the mitral valve annulus.

[0009] Dilation of the annulus of the mitral valve prevents the valve
leaflets from fully coapting when the valve is closed. Mitral
regurgitation of blood from the left ventricle into the left atrium
results in increased total stroke volume and decreased cardiac output,
and ultimate weakening of the left ventricle secondary to a volume
overload and a pressure overload of the left atrium.

[0010] Chronic or acute left ventricular dilatation can lead to papillary
muscle displacement with increased leaflet tethering due to tension on
chordae tendineae, as well as annular dilatation.

SUMMARY OF THE INVENTION

[0011] In some applications of the present invention, apparatus is
provided comprising an implant comprising one or more primary adjustable
repair chords and an adjustment mechanism that is configured to adjust a
tension of the one or more adjustable repair chords and that is slidable
along a guidewire toward an implantation site. Additionally, the
apparatus comprises a first tissue-engaging element (e.g., a tissue
anchor) that comprises one or more docking stations. Further
additionally, in accordance with some applications of the present
invention, a method is provided for implanting such apparatus. A
respective guidewire is reversibly coupled to each one of the docking
stations. The adjustment mechanism is slidable along the guidewire toward
one of the one or more docking stations, and is coupled to the
tissue-engaging element via the docking station. Thus, the docking
station is a coupling element that provides coupling between two other
elements (in this case, between adjustment mechanism and the
tissue-engaging element.)

[0012] The repair chord comprises a flexible, longitudinal member (e.g.,
sutures or wires). The repair chord is coupled at a distal portion
thereof to the adjustment mechanism. In some applications, the repair
chord functions as artificial chordae tendineae. In other applications,
the repair chord is used to adjust a distance between two portions of the
ventricular wall. For some applications, the repair chord is coupled at a
proximal portion thereof to a second tissue-engaging element (e.g., a
tissue anchor which penetrates or clips a portion of tissue).

[0013] For other applications, the repair chord comprises a cord that is
disposed within at least a portion of an annuloplasty ring structure
(e.g., a full annuloplasty ring or a partial annuloplasty ring). For such
applications, the annuloplasty ring structure comprises the adjustment
mechanism that is coupled to the repair cord. The annuloplasty ring
structure is slidable along the guidewire toward one of the one or more
docking stations, and is coupled to the tissue-engaging element via the
docking station. It is to be noted that the annuloplasty ring structure
may be provided independently of the adjustment mechanism and the repair
chord. For such applications, the annuloplasty ring structure is slidable
along the guidewire toward one of the one or more docking stations, and
is coupled to the tissue-engaging element via the docking station.

[0014] For yet other applications, a prosthetic heart valve and/or a
support for the prosthetic heart valve is slidable along the guidewire
toward one of the one or more docking stations, and is coupled to the
tissue-engaging element via the docking station.

[0015] Thus, the tissue-engaging element and the docking station are used
to facilitate implantation of an implant such as cardiac valve implants,
namely annuloplasty ring structures, prosthetic valves, and/or apparatus
for receiving a prosthetic valve (e.g., a docking station or a support
for receiving the prosthetic valve).

[0016] Typically, during a transcatheter procedure, the first
tissue-engaging element is coupled to a first portion of tissue at a
first implantation site in a heart of a patient. The adjustment mechanism
is then slid along the guidewire and toward the first tissue-engaging
element at the first implantation site. The proximal portion of the
repair chord is then coupled via the second tissue-engaging element to a
second portion of tissue at a second implantation site. Following the
coupling of the second tissue-engaging element to the second implantation
site, the adjustment mechanism is further slid distally toward the first
tissue-engaging element and is then coupled to the first tissue-engaging
element via the one or more docking stations on the first tissue-engaging
element. Following the coupling of the adjustment mechanism to the second
tissue-engaging element, a length and tension of the repair chord is then
adjusted in order to adjust a distance between the first and second
implantation sites. For applications in which the repair chord functions
as an artificial chordae tendineae, the adjustment of the length and
tension of the repair chord draws the leaflets together, and/or pulls the
leaflet down toward the first implantation site to repair the valve.

[0017] In some applications of the present invention, the adjustment
mechanism comprises a spool assembly which adjusts a degree of tension of
the repair chord. The spool assembly comprises a housing, which houses a
spool to which a distal portion of the repair chord is coupled.

[0018] For applications in which the repair chord is coupled to two
respective portions of the ventricular wall, the two portions are drawn
together, thereby restoring the dimensions of the heart wall to
physiological dimensions, and drawing the leaflets toward one another.

[0019] In some applications of the present invention, the adjustment
mechanism comprises a reversible locking mechanism which facilitates
bidirectional rotation of the spool in order to effect both tensioning
and relaxing of the repair chord. That is, the spool is wound in one
direction in order to tighten the repair chord, and in an opposite
direction in order to slacken the repair chord. Thus, the spool
adjustment mechanism facilitates bidirectional adjustment of the repair
chord.

[0020] In some applications of the present invention, the adjustable
repair chord is implanted during an open-heart or minimally-invasive
procedure. In these applications, the delivery tool comprises a handle
and a multilumen shaft that is coupled at a distal end thereof to the
adjustment mechanism. The delivery tool functions to advance the
adjustment mechanism to the first portion of tissue, implant the
adjustment mechanism at the first portion of tissue, and effect
adjustment of the repair chord by effecting rotation of the spool. For
applications in which the repair chord functions as an artificial chordae
tendineae, prior to implantation of the adjustment mechanism, the distal
portion of the delivery tool and the adjustment mechanism coupled thereto
are advanced between the leaflets of the atrioventricular valve and into
the ventricle toward the first portion of tissue. The incision made in
the heart is then closed around the delivery tool and the heart resumes
its normal function during the adjustment of the length of the artificial
chordae tendineae.

[0021] In some applications of the present invention, apparatus and method
described herein may be used for providing artificial chordac tendineac
in a left ventricle of the heart and effecting adjustment thereof. In
some applications, apparatus and method described herein may be used for
providing artificial chordae tendineae in a right ventricle of the heart
and effecting adjustment thereof. In some applications, apparatus and
method described herein may be used for providing a system to adjust a
length between two portions of the heart wall. For other applications
apparatus and method described herein may be used for providing a docking
station for an annuloplasty ring or for a prosthetic valve.

[0022] In some applications of the present invention, a guide member,
comprising a chord-engaging element that is slidably couplable to chordae
tendineae of the patient is used to guide a deployment tool to a
papillary muscle of the patient, so as to facilitate anchoring of a
tissue anchor (e.g., a tissue anchor of a docking assembly) to the
papillary muscle.

[0023] There is therefore provided, in accordance with an application of
the present invention, apparatus for facilitating anchoring of a tissue
anchor to a papillary muscle of a heart of a subject, the papillary
muscle being coupled to one or more chordae tendineae of the heart of the
subject, the apparatus being configured to be used with a guidewire, and
including:

[0024] a housing, percutaneously deliverable to the heart of the subject,
slidable along the guidewire, and shaped to define at least one opening;

[0025] a guide member, percutaneously deliverable to the heart of the
subject, percutaneously removable from the subject, couplable to the
housing, and having:

[0026] a distal portion, including a
chord-engaging element, configured to be percutaneously slidably coupled
to at least one of the one or more chordac tendineae, and decouplable
from the at least one of the one or more chordae, and

[0027] a proximal
portion, including a longitudinal element; and

[0028] a deployment tool, configured (1) to be reversibly coupled to the
anchor, (2) to be slidably coupled to the longitudinal element of the
guide member, and (3) to anchor the tissue anchor to the papillary muscle
of the subject.

[0029] In an application, the housing is configured to be decoupled from
the guide member before the deployment tool is coupled to the guide
member.

[0030] In an application, the tissue anchor includes a helical tissue
anchor, and the deployment tool is configured to anchor the tissue anchor
to the papillary muscle of the subject by rotating the tissue anchor.

[0031] In an application, the deployment tool includes a lance, configured
to stabilize the deployment tool at the papillary muscle of the subject
by penetrating tissue of the papillary muscle.

[0032] In an application, the lance is retractable into the deployment
tool.

[0033] In an application, the apparatus further includes the anchor.

[0034] In an application, the guidewire includes a first guidewire, and
the apparatus further includes a second guidewire, reversibly coupled to
the anchor.

[0035] In an application, the apparatus further includes the guidewire,
the guidewire being configured to be transluminally advanced to a
vicinity of the one or more chordae tendineae of the subject.

[0036] In an application, the guidewire is configured to be transluminally
advanced such that a distal portion of the guidewire is disposed between
at least two chordae tendineae of the subject, the one or more chordae
tendineae including at least one of the at least two chordae tendineae of
the subject.

[0037] In an application, the housing is shaped to define a channel
therethrough, the housing being slidable along the guidewire by the
guidewire being slidable through the channel.

[0038] In an application, the chord-engaging element includes a helical
element, configured to be housed by the housing, to be advanced out of
the housing, and to form a helix outside of the housing.

[0039] In an application, the chord-engaging element is configured to be
generally straight when housed by the housing, and to curl into the helix
outside of the housing.

[0040] In an application, the chord-engaging element is configured to be
helical when housed by the housing.

[0041] There is further provided, in accordance with an application of the
present invention, a method for use with a papillary muscle of a heart of
a subject, the papillary muscle being coupled to one or more chordae
tendineae of the heart of the subject, the method including:

[0042] advancing a guide member to the chordae tendineae, the guide member
having a proximal portion that includes a longitudinal element, and a
distal portion that includes a chord-engaging element, configured to be
slidably coupled to the chordae tendineae;

[0043] coupling the chord-engaging element to at least one of the one or
more chordae tendineae;

[0044] sliding the chord-engaging element over the at least one of the
chordae tendineae toward the papillary muscle; and

[0045] advancing a tool toward the papillary muscle of the subject by
sliding the tool along the longitudinal element.

[0046] In an application, the chord-engaging element includes a helical
chord-engaging element, and coupling the chord-engaging element to the at
least one of the chordae tendineae includes wrapping the helical
chord-engaging element around the at least one of the chordae tendineae.

[0047] In an application, the method further includes, following the step
of advancing, anchoring a tissue anchor to ventricular muscle tissue
using the tool.

[0048] In an application, anchoring the tissue anchor includes anchoring
the tissue anchor to ventricular muscle tissue in a vicinity of the
papillary muscle.

[0049] In an application, anchoring the tissue anchor includes anchoring
the tissue anchor to ventricular muscle tissue within 1 cm of the
papillary muscle.

[0050] In an application, anchoring the tissue anchor includes anchoring
the tissue anchor to the papillary muscle.

[0051] In an application, anchoring the tissue anchor includes anchoring a
tissue anchor that is reversibly couplable to a guidewire.

[0052] In an application, the deployment tool includes a lance, and the
method further includes, prior to anchoring the tissue anchor,
stabilizing the tool with respect to the ventricular muscle tissue by
penetrating the ventricular muscle tissue with the lance.

[0053] In an application, the method further includes retracting the lance
into the deployment tool.

[0054] In an application, the step of advancing includes advancing, to the
heart of the subject, a housing that is slidable along the guide member.

[0055] In an application, the method further includes, prior to the step
of advancing, advancing a guidewire to a ventricle of the heart, and
advancing the housing includes sliding the housing over the guidewire.

[0056] In an application, advancing the guidewire includes advancing a
distal portion of the guidewire between at least two of the chordae
tendineae of the subject.

[0057] In an application, the method further includes, subsequent to the
step of advancing, sliding the chord-engaging element distally out of the
housing.

[0058] In an application, the method further includes, subsequent to the
step of coupling and prior to the step of advancing, proximally
withdrawing the housing and decoupling the housing from the guide member
while maintaining the coupling of the chord-engaging element to the at
least one of the one or more chordae tendineae.

[0059] In an application, sliding the chord-engaging element distally out
of the housing includes facilitating transitioning of the chord-engaging
element from a generally straight state into a helical state.

[0060] There is further provided, in accordance with an application of the
present invention, a method for use with a tissue anchor and a papillary
muscle of a heart of a subject, the papillary muscle being coupled to one
or more chordae tendineae of the heart of the subject, the method
including:

[0061] percutaneously advancing to the chordae tendineae, along a
guidewire that has been advanced to the chordae tendineae of the subject,
a housing, shaped to define at least one opening;

[0062] advancing a distal portion of a guide member out of the opening of
the housing, the distal portion of the guide member including a
chord-engaging element;

[0063] coupling the chord-engaging element to at least one of the one or
more chordae tendineae;

[0064] exposing a proximal portion of the guide
member out of the opening of the housing by withdrawing the housing
proximally with respect to the guide member, the proximal portion of the
guide member including a longitudinal element; and

[0065] anchoring the tissue anchor to ventricular muscle tissue of the
subject by advancing a deployment tool, reversibly couplable to the
tissue anchor, along the longitudinal element.

[0066] In an application, the method further includes, subsequently to the
step of coupling and prior to the step of anchoring, sliding the
chord-engaging element along the at least one chordae tendineae toward
the papillary muscle.

[0067] In an application, the method further includes decoupling the
housing from the guide member before advancing the deployment tool along
the longitudinal member.

[0068] In an application, the tissue anchor includes a helical tissue
anchor, and anchoring the tissue anchor includes rotating the tissue
anchor.

[0069] In an application, the guidewire includes a first guidewire, and
anchoring the tissue anchor includes anchoring a tissue anchor that is
reversibly couplable to a second guidewire.

[0070] In an application, anchoring the tissue anchor includes anchoring
the tissue anchor to ventricular muscle tissue in a vicinity of the
papillary muscle.

[0071] In an application, anchoring the tissue anchor includes anchoring
the tissue anchor to ventricular muscle tissue within 1 cm of the
papillary muscle.

[0072] In an application, anchoring the tissue anchor includes anchoring
the tissue anchor to the papillary muscle.

[0073] In an application, the deployment tool includes a lance, and the
method further includes, before anchoring the tissue anchor, stabilizing
the deployment tool with respect to the ventricular muscle tissue by
penetrating the ventricular muscle tissue with the lance.

[0074] In an application, the method further includes retracting the lance
into the deployment tool.

[0075] In an application, the step of advancing includes advancing the
chord-engaging element out of the opening of the housing such that the
chord-engaging element forms a helix outside of the housing.

[0076] In an application, advancing the chord-engaging element out of the
opening of the housing includes facilitating a transition of the
chord-engaging member from a generally straight state into a helical
state.

[0077] The present invention will be more fully understood from the
following detailed description of applications thereof, taken together
with the drawings, in which:

BRIEF DESCRIPTION OF THE DRAWINGS

[0078] FIGS. 1-2 are schematic illustrations of apparatus comprising a
tissue-engaging element comprising a docking station coupled to a
guidewire, in accordance with some applications of the present invention;

[0079] FIG. 3 is a schematic illustration of advancement of an adjustment
mechanism along the guidewire toward the docking station of FIGS. 1 and
2, in accordance with some applications of the present invention;

[0080] FIGS. 4-5 are schematic illustrations of engaging a leaflet with a
leaflet engaging element, in accordance with some applications of the
present invention;

[0081] FIG. 6 is a schematic illustration of coupling of the adjustment
mechanism of FIG. 3 to the docking station, in accordance with some
applications of the present invention;

[0082] FIGS. 7-9 are schematic illustrations of adjusting by the
adjustment mechanism a length of a repair chord coupled to the adjustment
mechanism, in accordance with some applications of the present invention;

[0083] FIG. 10 is a schematic illustration of the adjustment mechanism and
the repair chord, in accordance with some other applications of the
present invention; and

[0084] FIGS. 11A-F are schematic illustrations of a system and techniques
for use thereof, for delivering a tissue anchor to a papillary muscle of
a subject, in accordance with some applications of the invention.

DETAILED DESCRIPTION OF EMBODIMENTS

[0085] Reference is now made to FIGS. 1-2, which are schematic
illustrations of a system 20 comprising a docking assembly 150 for
implantation at a first implantation site 5 of a patient, in accordance
with some applications of the present invention. As shown in FIG. 2,
docking assembly 150 comprises a tissue-engaging element having (1) a
distal portion comprising a tissue anchor 50 (e.g., a helical tissue
anchor as shown by way of illustration and not limitation), and (2) a
proximal portion comprising a docking platform 54, and at least one
docking station 56. Thus, docking assembly 150 comprises (a) the distal
portion which engages the tissue of the patient (i.e., the
tissue-engaging element), and (b) the proximal portion which is coupled
to docking station 56. At least one guide member, (e.g., a guidewire 40,
shown in FIG. 2) is reversibly coupled to docking assembly 150 (e.g., by
being looped around, or otherwise coupled to, a portion of assembly 150)
so as to define first and second portions 40a and 40a' that extend away
from assembly 150.

[0086] Tissue anchor 50 is typically implanted within cardiac tissue in a
manner in which a distal portion of anchor 50 does not extend beyond an
epicardium of heart 2 of the patient. Thus, anchor 50 is implanted at an
intracardiac site such that the implant, (e.g., the adjustment mechanism
or an implant comprising the adjustment mechanism) that is eventually
coupled thereto (as described hereinbelow) is implanted at the
intracardiac site such that no portions of the adjustment mechanism
extend beyond the epicardium of the heart.

[0087] Docking assembly 150 and guidewire 40 are advanced toward
implantation site typically during a transcatheter procedure, as shown.
However, it is to be noted that the scope of the present invention
includes the advancement of assembly 150 and guidewire 40 during a
minimally-invasive or open-heart procedure. The procedure is typically
performed with the aid of imaging, such as fluoroscopy, transesophageal
echo, and/or echocardiography.

[0088] The transcatheter procedure typically begins with the advancing of
a semi-rigid guidewire into a right atrium of the patient. The semi-rigid
guidewire provides a guide for the subsequent advancement of a sheath 28
therealong and into the right atrium. For some applications, once sheath
28 has entered the right atrium, the semi-rigid guidewire is retracted
from the patient's body. Sheath 28 typically comprises a 13-20 F sheath,
although the size may be selected as appropriate for a given patient.
Sheath 28 is advanced through vasculature into the right atrium using a
suitable point of origin typically determined for a given patient. For
example:

[0089] sheath 28 may be introduced into the femoral vein of
the patient, through an inferior vena cava, into the right atrium, and
into the left atrium transseptally, typically through the fossa ovalis;

[0090] sheath 28 may be introduced into the basilic vein, through the
subclavian vein to the superior vena cava, into the right atrium, and
into the left atrium transseptally, typically through the fossa ovalis;
or

[0091] sheath 28 may be introduced into the external jugular vein,
through the subclavian vein to the superior vena cava, into the right
atrium, and into the left atrium transseptally, typically through the
fossa ovalis.

[0092] In some applications of the present invention, sheath 28 is
advanced through the inferior vena cava of the patient (as shown) and
into the right atrium using a suitable point of origin typically
determined for a given patient.

[0093] Sheath 28 is advanced distally until the sheath reaches the
interatrial septum. For some applications, a resilient needle and a
dilator (not shown) are advanced through sheath 28 and into the heart. In
order to advance sheath 28 transseptally into the left atrium, the
dilator is advanced to the septum, and the needle is pushed from within
the dilator and is allowed to puncture the septum to create an opening
that facilitates passage of the dilator and subsequently sheath 28
therethrough and into the left atrium. The dilator is passed through the
hole in the septum created by the needle. Typically, the dilator is
shaped to define a hollow shaft for passage along the needle, and the
hollow shaft is shaped to define a tapered distal end. This tapered
distal end is first advanced through the hole created by the needle. The
hole is enlarged when the gradually increasing diameter of the distal end
of the dilator is pushed through the hole in the septum.

[0094] The advancement of sheath 28 through the septum and into the left
atrium is followed by the extraction of the dilator and the needle from
within sheath 28. Subsequently, a docking-assembly delivery tool 30 is
advanced through sheath 28. Tool 30 is typically advanced within a lumen
of an advancement sheath 22 having a distal end 24. Advancement sheath 22
is advanced within sheath 28. Delivery tool 30 is coupled at a distal end
thereof to a manipulator 32 which is reversibly coupled to docking
station 56 and docking platform 54 of docking assembly 150. Manipulator
32 has (1) lateral arms which cup platform 54, and (2) a
docking-station-coupler 34, as shown in FIG. 1. Coupler 34 is biased to
move radially-inward, as shown in FIG. 1. Docking station 56 is ribbed,
such that coupler 34, when moved radially inward, engages at least one
rib of docking station 56, thereby coupling assembly 150 to delivery tool
30.

[0095] Delivery tool 30 and manipulator 32 are shaped so as to define a
lumen for passage therethrough of guidewire 40.

[0096] Docking assembly 150 is implanted in implantation site 5 by
rotating tool 30 in order to rotate anchor 50 and corkscrew anchor 50
into tissue of site 5. Site 5 typically comprises a portion of tissue at
an intraventricular site in heart 2 of the patient. As shown, site 5
includes a papillary muscle 4, by way of illustration and not limitation.
It is to be noted that site 5 includes any portion of cardiac tissue,
e.g., a portion of a free wall of the ventricle, a portion of the septum
facing the ventricle, a portion of tissue at a base of the papillary
muscle, or a portion of the wall at the apex of the ventricle. (For the
purposes of the claims, "a portion of tissue of a ventricle" includes any
portion of cardiac tissue, e.g., a portion of a free wall of the
ventricle, a portion of the septum facing the ventricle, a portion of
tissue at a base of the papillary muscle, or a portion of the wall at the
apex of the ventricle.)

[0097] Following the implantation of assembly 150 at site 5, tool 30 is
disengaged from assembly 150 when the physician pulls on tool 30. This
pulling pulls on manipulator 32 such that coupler 34 is actively moved
radially outward against the ribs of docking station 56, and is thereby
decoupled from station 56. At the time of pulling, tissue at implantation
site 5 pulls on assembly 150 (in the direction opposite the direction of
pulling by the physician) so as to help disengage tool 30 from assembly
150.

[0098] As shown in FIG. 2, following the decoupling of tool 30 from
assembly 150, tool 30 is pulled proximally along guidewire 40 and is
extracted from the body of the patient together with advancement sheath
22, leaving behind assembly 150 and guidewire 40.

[0099] FIG. 3 shows advancement of an implant (e.g., a spool assembly 36
comprising an adjustment mechanism 43) along guidewire 40 by an
adjustment-mechanism delivery tool 64, in accordance with some
applications of the present invention. Tool 64 is surrounded by and
slidable within an advancement sheath 60 having a distal end 62.

[0100] Spool assembly 36 is surrounded by a braided fabric mesh, e.g., a
polyester mesh, which promotes fibrosis around assembly 36 and
facilitates coupling of assembly 36 to tissue of heart 2. Assembly 36
houses a rotatable structure (e.g., a spool as shown hereinbelow) that is
surrounded by a housing 49. Housing 49 is coupled to a distal cap 44
which facilitates coupling of assembly 36 to docking station 56 of
docking assembly 150. As shown, cap 44 is shaped so as to define a
plurality of baffles 47 that are disposed angularly with respect to a
distal end of cap 44. Baffles 47 are coupled to the distal end of cap 44
along respective coupling joints which facilitate movement of each baffle
47. During the coupling of spool assembly 36 to docking station 56, the
ribbed portion of docking station 56 pushes inwardly baffles 47 of cap
44, as is described hereinbelow. Baffles 47 then expand and engage an
area of docking station 56 between the ribs of the ribbed portion so as
to dock and lock assembly 36 to docking station 56.

[0101] Additionally, cap 44 is shaped so as to define a central opening
therethrough which facilitates passage therethrough of guidewire 40.
Additionally, spool assembly 36 and the components thereof are shaped so
as to define a central opening (i.e., an opening having the same axis as
guidewire 40). That is, spool 46 has a central opening, and housing 49
has a central opening which facilitates passage of spool 46 and housing
49 along guidewire 40.

[0102] As shown, adjustment mechanism 43 is coupled to a distal portion of
a repair chord 74 (e.g., repair chord 74 is looped through or otherwise
coupled to a portion of adjustment mechanism 43). Chord 74 comprises a
flexible longitudinal member. For some applications, and as is described
hereinbelow, chord 74 functions as an artificial chordae tendineae. A
proximal portion of chord 74 is coupled to a leaflet-engaging element 72
(e.g., a clip, as shown). Leaflet-engaging element 72 is disposed within
a holder 70 that is coupled to delivery tool 64. Chord 74 a superelastic,
biocompatible material (e.g., nitinol, ePTFE, PTFE, polyester, stainless
steel, or cobalt chrome). Typically, chord 74 comprises an artificial
chordae tendineae.

[0103] FIGS. 4-5 are schematic illustrations of the engaging of
leaflet-engaging element 72 to at least one leaflet 14 of a mitral valve
of the patient, in accordance with some applications of the present
invention. As shown in FIG. 4, the clip is opened from a remote location
outside the body of the patient.

[0104] For some applications, the clip typically is shaped so as to define
at least one coupling protrusion 73. The clip has a tendency to close,
and is initially held open by a cord (not shown) that is coupled to a
surface of the clip, extends through delivery tool 64, and is held taught
outside of the heart. Once the clip has been advanced to the desired
location on the leaflet, the cord is relaxed, allowing the clip to close.
The cord is removed, typically by releasing one end thereof and pulling
the other end. The positioning of holder 70 between the leaflets (FIG. 5)
helps ensure that the clip engages exactly one of the leaflets. It is
noted that in FIG. 5 the clip is shown engaging only a single leaflet
(leaflet 14). The clip typically engages the leaflet by clamping the
leaflet such that the clip engages atrial and ventricular surfaces of the
leaflet. The clip may puncture the leaflet, or may merely press firmly
against the leaflet.

[0105] It is to be noted that the scope of the present invention include
the clipping together of both leaflets 12 and 14. For applications in
which system 20 is used to repair a tricuspid valve of the patient, the
clip may clip any one, two, or all three leaflets together.

[0106] Holder 70 is shaped to define a groove which houses the clip during
the advancement of tool 64 toward the ventricle. The groove functions as
a track to facilitate slidable detachment of the clip from holder 70
following the engaging of the clip to leaflet 14.

[0107] Alternatively, the clip has a tendency to open. In order to close
the clip, a cord is provided. A distal-most portion of the cord is looped
around the clip. Once the clip has been advanced to the desired location
on the leaflet, as shown in FIG. 5, the surgeon pulls on both ends of the
cord, thereby causing the clip to become locked closed. The cord is
removed, typically by releasing one end thereof and pulling the other
end.

[0108] It is to be noted that the scope of the present invention includes
any leaflet-engaging element known in the art.

[0109] As shown in FIG. 5, portions 74a and 74b extend from
leaflet-engaging element 72 toward adjustment mechanism 43. Portions 74a
and 74b define portions of a single chord 74 that is looped through a
portion of mechanism 43. Alternatively, portions 74a and 74b represent
two distinct chords which are coupled at their distal ends to adjustment
mechanism 43 and at their proximal ends to leaflet-engaging element 72.

[0111] FIG. 6 shows spool assembly 36 being coupled to docking station 56,
in accordance with some applications of the present invention. Following
the coupling of leaflet-engaging element 72 to leaflet 14, spool assembly
36 is pushed distally toward docking station 56. Spool assembly 36 is
coupled to an advancement shaft 80 which pushes assembly 36. Shaft 80
slides within a lumen of delivery tool 64 and within a lumen of holder 70
so as to advance spool assembly 36, while leaflet-engaging element 72
remains engaged with leaflet 14. Advancement shaft 80 functions to
advance distally spool assembly 36 and functions to facilitate engagement
between spool assembly 36 and docking station 56.

[0112] As described hereinabove, docking station 56 has one or more
locking mechanisms (e.g., one or more ribs 57, shown in the enlarged
cross-sectional image of FIG. 6) which project laterally such that rib 57
defines a shelf and an depressed area underneath the shelf (i.e., the
cross-sectional diameter at rib 57 is larger than the cross-sectional
diameter at the area underneath the shelf). As described hereinabove, cap
44 of assembly 36 is shaped so as to define a plurality of baffles 47. As
cap 44 engages docking station 56, baffles 47 are pushed inward and
upward angularly as each baffle slides against rib 57. After each baffle
47 passes the shelf of rib 57, the baffle engages the depressed area
underneath the shelf of rib 57, as shown in the enlarged cross-sectional
image of FIG. 6. The shelf of rib 57 prevents upward movement of baffles
47 and thereby locks in place baffles 47 and cap 44 with respect to
docking station 56. Rib 57, therefore, comprises a locking mechanism so
as to lock implant 42 (e.g., adjustment mechanism 43) to tissue anchor
50.

[0113] Following the coupling of assembly 36 to docking station 56, spool
46 is rotated in a first rotational direction in order to advance with
respect to spool 46 and contact with spool 46 successive portions of
chord 74. For example, when the successive portions of chord 74 are
advanced with respect to spool 46, the successive portions of chord 74
are looped around spool 46. The rotating of spool 46 in the first
rotational direction pulls tight and adjusts a length of chord 74 between
leaflet 14 and spool 46, in order to adjust a distance between leaflet 14
and implantation site 5 and to facilitate coaptation between leaflets 12
and 14, as is described hereinbelow.

[0114] Housing 49 is shaped so as to provide openings 41a and 41b for
passage therethrough of portions 74a and 74b, respectively, of chord 74
into housing 49. For some applications of the present invention, portions
74a and 74h define portions of a single chord 74 that is looped through
spool 46. For other applications, portions 74a and 74b define discrete
chords which are each coupled at respective distal ends thereof to spool
46.

[0115] The enlarged, cross-sectional image of FIG. 6 shows spool 46 within
housing 49. Spool 46 defines an upper surface 150, a lower surface 152,
and a cylindrical body portion disposed vertically between surfaces 150
and 152. Spool 46 is shaped to provide a driving interface, e.g., a
channel, which extends from an opening provided by upper surface 150 to
an opening provided by lower surface 152. A proximal portion of the
driving interface is shaped to define a threaded portion 146 which may or
may not be tapered. Threaded portion 146 of spool 46 is engageable by a
threaded portion of a screwdriver head 92 of a screwdriver 90.
Screwdriver 90 is coupled to a distal end of shaft 80. For some
applications, shaft 80 rotates screwdriver 90. For other applications,
shaft 80 is shaped so as to define a lumen for advancement therethrough
of a screwdriver-rotation tool that facilitates rotation of screwdriver
90. Rotation of screwdriver 90 and screwdriver head 92 rotates spool 46,
as the respective threaded portions of spool 46 and screwdriver head 92
engage. The cylindrical body portion of spool 46 is shaped to define one
or more holes which function as respective coupling sites for coupling
(e.g., looping through the one or more holes, or welding to spool 46 in
the vicinity of the one or more holes) of any number of chords 74 to
spool 46.

[0116] Lower surface 152 of spool 46 is shaped to define one or more
(e.g., a plurality, as shown) recesses 154 which define structural
barrier portions 155 of lower surface 152. It is to be noted that any
suitable number of recesses 154 may be provided, e.g., between 1 and 10
recesses, circumferentially or otherwise, with respect to lower surface
152 of spool 46.

[0117] As shown, a locking mechanism 45 is disposed in communication with
lower surface 152 of spool 46 and disposed in communication with at least
in part to a lower surface of housing 49. Typically, a cap 44 maintains
locking mechanism 45 in place with respect to lower surface 152 of spool
46 and lower surface of housing 49. For some applications, locking
mechanism 45 is coupled, e.g., welded, to the lower surface of housing
49. Typically, locking mechanism 45 defines a mechanical element having a
planar surface that defines slits. It is to be noted that the surface of
locking mechanism 45 may also be curved, and not planar. Locking
mechanism 45 is shaped to provide a protrusion 156 which projects out of
a plane defined by the planar surface of the mechanical element. The
slits of mechanism 45 define a depressible portion 128 that is disposed
in communication with and extends toward protrusion 156. Depressible
portion 128 is moveable in response to a force applied thereto typically
by an elongate locking mechanism release rod 94 which slides through a
lumen of screwdriver 90 and a torque-delivering tool that is coupled
thereto.

[0118] It is to be noted that the planar, mechanical element of locking
mechanism 45 is shown by way of illustration and not limitation and that
any suitable mechanical element having or lacking a planar surface but
shaped to define at least one protrusion may be used together with
locking mechanism 45.

[0119] Cap 44 is provided that is shaped to define a planar surface and an
annular wall having an upper surface thereof. The upper surface of the
annular wall is coupled to, e.g., welded to, a lower surface provided by
housing 49. The annular wall of cap 44 is shaped to define a recessed
portion 144 of cap 44 that is in alignment with a recessed portion 142 of
spool housing 49.

[0120] As shown, a distal end 96 of locking mechanism release rod 94
pushes distally on depressible portion 128 in order to unlock locking
mechanism 45 from spool 46. Pushing depressible portion 128 by locking
mechanism release rod 94 pushes distally protrusion 156 within recessed
portion 142 of housing 49 and within recessed portion 144 of cap 44,
which frees protrusion 156 from recesses 154 of spool 46. Once protrusion
156 is released from recesses 154 of spool 46, the physician is able to
rotate spool 46 bidirectionally in order to adjust a tension of chord 74.

[0122] In the resting state (i.e., prior to the rotation of spool 46 in
order to adjust chord 74, following coupling of leaflet-engaging element
72 to leaflet 14) chord 74 is wrapped around spool 46 a few times (e.g.,
three times, by way of illustration and not limitation). This winding
provides excess slack to chord 74 (in case portions 74a and 74b are
coupled too tightly to leaflet 14). If the physician wishes to provide
slack to member 74 or to any one of portion 74a or 74b, the physician
unwinds a bit of the wrapped portion of member 74 from around spool 46
(e.g., by unwinding chord 74 a few times from around spool 46, or by
unwinding chord 74 entirely from around spool 46 so that chord 74 slides
freely through spool 46 within a channel provided therein). In order to
accomplish such unwinding, the physician rotates spool 46 in a rotational
direction in which it unwinds the wrapped portion of chord 74. Since
chord 74 is looped through spool 46 in the channel provided therein, when
chord 74 is unwound from spool 46, the physician can pull on one or both
portions 74a and 74b so as to adjust, make even, or further slacken any
one of or both portions 74a and 74b that extend from spool 46.

[0123] When the physician desires to pull tight chord 74, he or she
effects rotation of spool 46 in a first rotational direction, i.e. the
direction opposite the second rotational direction in which spool 46 is
rotated during the unwinding of chord 74 from spool 46. Rotation of spool
46 in the first rotational direction winds chord 74 around spool 46,
while rotation of spool 46 in a second rotational direction that is
opposite the first rotational direction, unwinds the portion of
longitudinal chord 74 from around spool 46.

[0124] FIG. 7 shows spool assembly 36 following the adjustment of chord 74
by rotating screwdriver 90 in the direction as indicated by the arrow,
and the partial removal of screwdriver 90, in accordance with some
applications of the present invention. As shown in the enlarged
cross-sectional image of FIG. 7, successive portions of chord 74 are
wrapped around spool 46. That is, chord 74 is wrapped more times around
spool 46 following adjustment (e.g., an additional 4 times, as shown in
FIG. 7), than prior to adjustment (FIG. 6). This pulls chord 74 from a
slackened state (FIG. 6) to a taut state (FIG. 7) in order to adjust a
length of chord 74 between adjustment mechanism 43 and the proximal end
of chord 74 that is coupled to leaflet-engaging element 72. Additionally,
this applying of tension to chord 74 adjusts a length between first and
second implantation sites 5 and 7. Typically, chord 74 is adjusted while
heart 2 is beating.

[0125] As shown, rod 94 is shaped so as to define a central lumen and a
distal opening for passage therethrough of guidewire 40. Additionally,
depressible portion 128 is shaped so as to provide an opening for passage
of guidewire 40 therethrough. Guidewire 40 is looped around a distal
looping element 55 of docking platform 54 of docking assembly 150.
Following the adjusting of the tension and length of chord 74,
screwdriver 90 is decoupled from spool 46 (e.g., by being unscrewed from
threaded portion 146 of spool 46) and is advanced proximally together
with rod 94 away from spool assembly 36, as shown in the enlarged,
cross-sectional image of FIG. 7.

[0126] Following the decoupling of screwdriver 90 from spool 46 and the
removal of screwdriver 90, guidewire 40 remains coupled to docking
platform 54 and docking assembly 150. Guidewire 40 then facilitates
subsequent advancement of screwdriver 90 or any other tool to access
spool assembly 36 and/or to facilitate further adjustment of chord 74
beyond the initial adjustment. Guidewire 40 may remain chronically
coupled to docking assembly 150 and may be accessible at a subcutaneous
location of the patient, e.g., a port. For other applications, guidewire
40 is removed from docking assembly 150 when the physician determines
that further adjustment of chord 74 is not needed. The physician removes
guidewire 40 by pulling, from outside the body of the patient, one end of
guidewire 40 so that guidewire 40 slides around element 55 and is
unlooped therefrom. The physician continues to pull on the end of
guidewire 40 until the second end of wire 40 is exposed and removed from
the patient.

[0127] Following the removal of locking-mechanism release rod 94,
depressible portion 128 is no longer depressed by distal end 96 of rod
94, and protrusion 156 returns within a recess 154 of spool 46 so as to
lock spool 46 in place and restriction rotation thereof in either
direction (FIG. 7).

[0128] Reference is now made to FIGS. 3-7. It is to be noted that spool
assembly 36 is only coupled to docking assembly 150 following the
coupling of leaflet-engaging element 72 to leaflet 14. This is done in
order to reduce the strain on implantation site 5. Should spool assembly
36 be implanted at implantation site 5 prior to engaging leaflet 14 with
leaflet-engaging element 72, more strain would be applied to implantation
site 5 than if spool assembly 36 had been implanted following the
coupling of leaflet-engaging element 72 to leaflet 14, as described
herein. That is, the pulling force is applied in a downward direction
from leaflet 14 toward implantation site 5 instead of from implantation
site 5 upward toward leaflet 14.

[0129] FIG. 8 shows system 20 following the removal of the tool used to
rotate spool 46 of spool assembly 36, in accordance with some
applications of the present invention. As shown, chord 74 is pulled tight
such that its length and tension are adjusted, and leaflet 14 is pulled
and adjusted commensurate with the adjustment of chord 74. Guidewire 40
remains coupled to spool assembly 36 and to docking assembly 150, as
shown, such that portions 40a and 40a' extend from spool assembly 36.
Guidewire 40 facilitates the reintroduction of the tool used to rotate
spool 46, or of any other tool.

[0130] FIG. 9 shows system 20 following the removal of guidewire 40 from
heart 2, in accordance with some applications of the present invention.
As shown, the adjustment of chord 74 draws leaflets 12 and 14 together.
It is to be noted that although leaflet-engaging element 72 is shown as
engaging only leaflet 14, the scope of the present invention includes the
engaging of both leaflets 12 and 14 by leaflet-engaging element 72.

[0131] FIG. 10 shows a system 220, as described hereinabove with reference
to system 20, with the exception that implantation site 5 includes tissue
of the wall of the ventricle at the base of papillary muscle 4 in a
vicinity of the apex of the heart, in accordance with some applications
of the present invention. Implantation site 5 is shown by way of
illustration and not limitation, and as described hereinabove, site 5 may
include any portion of tissue of heart 2. It is to be noted that although
leaflet-engaging element 72 is shown as engaging only leaflet 14, the
scope of the present invention includes the engaging of both leaflets 12
and 14 by leaflet-engaging element 72.

[0132] Reference is now made to FIGS. 11A-F, which are schematic
illustrations of a system 240 and techniques for use thereof, for
delivering a tissue anchor 280 to a papillary muscle of a subject, in
accordance with some applications of the invention. For some applications
of the invention, tissue anchor 280 comprises tissue anchor 50 of docking
assembly 150, described hereinabove. Alternatively, tissue anchor 280 may
comprise a different tissue anchor. Similarly, tissue anchor 280 may
comprise a helical tissue anchor, as shown in FIGS. 11A-F by way of
illustration and not limitation, or may comprise a different tissue
anchor.

[0133] As described hereinabove (e.g., with reference to FIGS. 1-2),
transcatheter access to heart 2 typically begins with the advancing of a
semi-rigid guidewire into the left atrium of the patient, and sheath 28
is subsequently advanced along (e.g., over) the guidewire, to the left
atrium. Typically, but not necessarily, this is performed using a
standard transseptal puncture procedure, and further typically, the
guidewire is advanced to the heart transfemorally, as shown.
Alternatively, the guidewire may be advanced using a retrograde approach,
via the aorta of the subject. Similarly, any suitable approach may be
used such as, but not limited to, those described with reference to FIGS.
1-2. For some applications, such that those described with reference to
FIGS. 11A-F, the guidewire is not immediately retracted from the body of
the patient. The guidewire is shown in FIGS. 11A-F as a guidewire 242.
Typically, guidewire 242 is advanced such that it passes leaflets 12 and
14, and reaches and/or passes one or more chordae tendineae 244 (FIG.
11A). For some applications, guidewire 242 passes between two or more
chordae tendineae 244. For some applications guidewire 242 is configured
(e.g., shape-set) to facilitate such positioning. FIG. 11A also shows a
chord-engaging tool 246 being subsequently advanced distally along
guidewire 242, toward chordae tendineae 244.

[0134] A distal portion of chord-engaging tool 246 comprises or defines a
housing 248, and the chord-engaging tool is advanced such that housing
248 is disposed in a vicinity of (e.g., close to and/or touching) one or
more of the chordae tendineae (FIG. 11B). Typically, tool 246 (e.g.,
housing 248 thereof) is shaped to define a channel 247 therethrough,
through which guidewire 242 is slidable. Disposed within housing 248 is
at least part of a guide member 250, which has a distal portion and a
proximal portion. The distal portion of guide member 250 comprises a
chord-engaging element, such as, but not limited to, a helical
chord-engaging element 252, which is configured to be slidably coupled to
at least one of the chordae tendineae.

[0135] FIG. 11B shows element 252 having been advanced out of an opening
249 defined by housing 248, and forming a helix outside of the housing.
For some applications, when disposed within housing 248, element 252 is
generally straight (e.g., is held generally straight within a lumen of
the housing), and curls into the helix as it emerges from the housing.
Alternatively, element 252 is also helical when disposed within housing
248. Element 252 wraps around one or more of the chordae tendineae as the
element forms the helix outside of the housing. For some applications,
element 252 is rotated to facilitate this wrapping. Similarly, housing
248, element 252, and guidewire 242 may be manipulated (e.g., moved back
and forth) to facilitate engagement of the chordae tendineae by element
252.

[0136] FIG. 11C shows chord-engaging tool 246 (including housing 248)
being subsequently moved distally such that chord-engaging element 252
slides distally along the one or more chordae tendineae that have been
engaged, such that element 252 reaches (e.g., touches) a papillary muscle
254 (e.g., the papillary muscle to which the chordae tendineae engaged by
element 252 is coupled).

[0137] Subsequently, tool 246 (including housing 248) is withdrawn
proximally, while guide member 250 is held in place (e.g., by a counter
force), such that tissue-engaging element 252 remains coupled to the
chordae tendineae in close proximity to (e.g., in contact with) papillary
muscle 254, and exposing the proximal portion of guide member 250,
comprising a longitudinal element 251. Typically, tool 246 (including
housing 248) is subsequently withdrawn into sheath 28, and further
typically, is decoupled from the guide member and/or removed from the
body of the patient.

[0138] FIG. 11E shows a deployment tool 260 being transcatheterally
advanced into heart 2 of the subject, and being slid along guide member
250 (e.g., along longitudinal element 251 thereof). For some
applications, tool 260 comprises one or more eyelets 262, slidable over
longitudinal element 251. For some applications, tool 260 is advanced via
an overtube 258, which may itself be advanced through sheath 28. For some
applications, tool 260 is advanced via tool 246 (e.g., via a lumen
therethrough), and overtube 258 in FIGS. 11E-F represents tool 246
functioning as an overtube.

[0139] Guide member 250 (e.g., longitudinal element 251 thereof) guides
deployment tool 260 toward papillary muscle 254. For some applications,
deployment tool 260 comprises a distal lance 264, configured to penetrate
tissue of papillary muscle 254, and to stabilize tool 260 at the
papillary muscle. For some such applications, lance 264 is retractable
into the body of tool 260. For applications in which deployment tool
comprises lance 264, the lance is typically slidable through a hole in
anchor 280. Alternatively, anchor 280 may comprise lance 264, and the
lance is configured to stabilize the anchor at the papillary muscle
during anchoring, e.g., during rotation of the anchor.

[0140] Deployment tool 260 is configured to anchor tissue anchor 280 to
papillary muscle 254. For some applications, and as shown in FIG. 11E,
tissue anchor 280 is reversibly coupled to the distal end of tool 260.
For some applications, the tissue anchor is housed within tool 260 and is
advanced out of the tool prior to or during anchoring. For applications
in which anchor 280 comprises a helical anchor, the anchor is typically
anchored to the papillary muscle by being rotated by tool 260, or by a
component thereof.

[0141] For some applications, system 240 is configured to facilitate
anchoring of tissue anchor 280 to other ventricular muscle tissue in the
vicinity of papillary muscle 254 (e.g., within 1 cm of the papillary
muscle). For example, a sufficient distance between (1) a distal-most
part of tool 260 at which the tool is slidably coupled to longitudinal
element 251 (e.g., the distal-most eyelet 262), and (2) a distal end of
anchor 280 may be provided to allow the tissue anchor to be anchored
slightly away from chord-engaging element 252 (e.g., within 1 cm of the
papillary muscle). Flexibility of longitudinal element 251 may
alternatively or additionally facilitate such anchoring of anchor 280.
Alternatively or additionally, the operating physician may stop advancing
tool 260 such that a length of guide member 250 (e.g., of longitudinal
element 251 thereof) between the distal-most eyelet 262 and
chord-engaging element 252 is sufficient to facilitate such anchoring of
anchor 280.

[0142] FIG. 11F shows guide member 250 and deployment tool 260 having been
retracted proximally (e.g., into overtube 258 and/or out of the body of
the patient), exposing a guidewire 282, reversibly coupled to anchor 280,
and extending proximally (e.g., into overtube 258 and/or out of the body
of the subject).

[0143] Chord-engaging element 252 is typically decoupled from chordae
tendineae 244 by withdrawing guide member 250 slightly proximally with
respect to tool 260, thereby straightening out the helix formed by
element 252. For example, the helix may be progressively drawn into tool
260, or past an eyelet 262 thereof, and responsively straighten.
Alternatively, chord-engaging element 252 may be decoupled from the
chordae tendineae using tool 246 (e.g., housing 248 thereof), such as by
re-advancing the tool distally, and withdrawing member 250, including
element 252 thereof, into the tool.

[0144] For some applications, chord-engaging element 252 is decoupled from
chordae tendineae 244 after anchoring of tissue anchor 280 (e.g., after
tissue anchor 280 has been partially or fully advanced into papillary
muscle 254). For some such applications, this is facilitated by
flexibility of element 252 (e.g., that which facilitates curling and
straightening thereof), e.g., by facilitating movement of element 252
through and/or around portions of anchor 280.

[0145] For some applications, chord-engaging element 252 is decoupled from
chordae tendineae 244 prior to anchoring of tissue anchor 280. For
example, chord-engaging element 252 may be decoupled from the chordae
tendineae subsequently to lance 264 penetrating tissue and thereby
stabilizing tool 260 and anchor 280 with respect to the tissue.

[0146] It is to be noted that guidewire 282 is a different guidewire to
guidewire 242, described with reference to FIGS. 11A-B. As described
hereinabove, for some applications, tissue anchor 280 comprises tissue
anchor 50 of docking assembly 150. Similarly, guidewire 282 may comprise
guidewire 40, described hereinabove, and may be reversibly coupled to
anchor 280 via a docking station 56 of the docking assembly.

[0147] It is to be noted that, although guidewire 242 is shown in FIGS.
11A-E as being present in heart 2, and is shown in FIG. 11F as having
been withdrawn from the heart, guidewire 242 may be withdrawn at any
point in the procedure following the coupling of chord-engaging element
252 to chordae tendineae 244 (FIG. 11B).

[0148] For some applications, the step shown in FIG. 11F is generally
similar to the step shown in FIG. 2. The apparatus and techniques
described with reference to FIGS. 11A-F may be used in combination with
the apparatus and techniques described with reference to FIGS. 1-10,
e.g., to facilitate anchoring of docking assembly 150 to a papillary
muscle. For some such applications, the step described with reference to
FIG. 11F may precede the step shown in FIG. 3, mutatis mutandis.

[0149] For some applications of the present invention, systems 20, 220,
and 240 are used to treat an atrioventricular valve other than the mitral
valve, i.e., the tricuspid valve. For these applications, systems 20,
220, and 240 placed in the right ventricle instead of the left ventricle.

[0150] It is to be noted that the scope of the present invention includes
the use of systems 20, 220, and 240 on other cardiac valves, such as the
pulmonary valve or the aortic valve.

[0151] It is to be further noted that the scope of the present invention
includes the use of systems 20, 220, and 240 on other tissue other than
cardiac tissue, e.g., gastric tissue or any other suitable tissue or
organ.

[0152] For some applications, system 240 and/or the techniques described
with reference to FIGS. 11A-F may be used to deliver a plurality of
tissue anchors 280 to the papillary muscle, and/or to deliver a plurality
of tissue anchors to a plurality of papillary muscles.

[0153] Additionally, the scope of the present invention includes
applications described in the following applications, which are
incorporated herein by reference. In an application, techniques and
apparatus described in one or more of the following applications are
combined with techniques and apparatus described herein:

[0171] U.S. patent application
Ser. No. 12/706,868 to Miller et al., entitled, "Actively-engageable
movement-restriction mechanism for use with an annuloplasty structure,"
filed on Feb. 17, 2010, which published as 2010/0211166; and/or

[0172]
U.S. patent application Ser. No. 12/795,026 to Miller et al., entitled,
"Apparatus for guide-wire based advancement of a rotation assembly,"
filed on Jun. 7, 2010, which published as 2011/0106245.

[0173] It will be appreciated by persons skilled in the art that the
present invention is not limited to what has been particularly shown and
described hereinabove. Rather, the scope of the present invention
includes both combinations and subcombinations of the various features
described hereinabove, as well as variations and modifications thereof
that are not in the prior art, which would occur to persons skilled in
the art upon reading the foregoing description.